A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?
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<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture1AB_1746709047.jpg" class="img-fluid" /></p>
The Correct Answer is B
A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.
B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will ask to have you assigned to a female nurse.": Respecting the client’s preference supports her autonomy, comfort, and dignity. Offering to accommodate her request shows sensitivity to her personal, cultural, or religious needs and helps maintain a trusting nurse-client relationship.
B. "I will get a female assistive personnel to provide your bath.": While providing a female assistive personnel for bathing might address part of the concern, it does not fully meet the client's expressed preference for all aspects of nursing care to be provided by a female nurse.
C. "You will need to speak with the nurse manager about this.": Asking the client to manage the reassignment request herself can seem dismissive. It is the nurse’s responsibility to advocate for the client and initiate steps to meet her needs whenever possible.
D. "I care for other female clients and they do not mind having a male nurse.": Comparing the client’s feelings to those of others invalidates her concerns and does not demonstrate respect for her individual preferences, which is essential in client-centered care.
Correct Answer is C
Explanation
A. Place the client on bedrest: While limiting the client’s activity is important to reduce oxygen demand, it is not the first priority. Immediate actions should focus on improving oxygenation and reducing respiratory distress.
B. Obtain the client's ABG levels: Although obtaining arterial blood gases provides valuable information about oxygenation and acid-base balance, it does not address the immediate need to relieve the client's breathing difficulty and hypoxia.
C. Elevate the head of the client's bed: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the first action to reduce dyspnea and ease the client’s breathing. It is a simple, quick intervention that can stabilize the client while further assessments are conducted.
D. Prepare the client for a ventilation-perfusion scan: A V/Q scan may be indicated to diagnose conditions like pulmonary embolism, but it is a diagnostic step that follows stabilization. Immediate efforts must first focus on ensuring adequate oxygenation and respiratory support.
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